Provider Demographics
NPI:1003114935
Name:WIJAYA, AIDA
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:WIJAYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 N IVANHOE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4824
Mailing Address - Country:US
Mailing Address - Phone:503-205-1600
Mailing Address - Fax:
Practice Address - Street 1:8330 N IVANHOE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4824
Practice Address - Country:US
Practice Address - Phone:503-205-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0010283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist